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Organization
FAMILY CLINIC AT THE LAKE PLLC
Active
Organization
FAMILY CLINIC AT THE LAKE PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ELLANIKOLE JACKSON NP (OWNER)
(731) 689-4357
Entity
Organization
Contact information
Practice address
11268 HIGHWAY 57, COUNCE, TN 38326-3802
(731) 689-4357
Mailing address
PO BOX 140, PICKWICK DAM, TN 38365-0140
(731) 689-4357
(731) 689-1050
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
Primary
—
NULL
363L00000X
Nurse Practitioner
—
NULL
363L00000X
Nurse Practitioner
—
—
Other
Enumeration date
06/28/2019
Last updated
10/14/2019
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